Article Text

Using structural equation modelling to characterise multilevel socioecological predictors and mediators of condom use among transgender women and cisgender men who have sex with men in the Philippines
1. Arjee Restar1,2,
4. Jennifer Nazareno1,2,
5. Laufred Hernandez3,
6. Theo Sandfort4,
7. Mark Lurie5,
8. Susan Cu-Uvin1,2,
9. Don Operario1,2
1. 1Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
2. 2The Philippine Health Initiative for Research, Service, and Training, Brown University School of Public Health, Providence, Rhode Island, USA
3. 3Department of Behavioral Sciences, University of the Philippines Manila, Manila, Metro Manila, Philippines
4. 4HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, New York, New York, USA
5. 5Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
1. Correspondence to Dr Arjee Restar; arjee_restar{at}brown.edu

## Abstract

Background Risks for condomless sex among transgender women and cisgender men who have sex with men (trans-WSM and cis-MSM, respectively) in the Philippines, where HIV recently became a national public health crisis, are shaped and exacerbated by various risk factors across multiple levels.

Methods Between June 2018 and August 2019, we conducted a cross-sectional online study with 318 trans-WSM and cis-MSM respondents from Manila and Cebu cities. Structural equational modelling procedures were performed to determine direct, indirect and overall effects between condom use and latent variables across multiple socioecological levels: personal (ie, condom self-efficacy), social (ie, social capital), environmental (ie, barriers to condom and HIV services) and structural (ie, structural violence, antidiscrimination policies).

Results Adjusted for gender, age, location and income, our model showed that: (1) all latent variables at the structural and environmental levels were significantly positively associated with each other (all ps<0.05); (2) barriers to condom and HIV services were significantly negatively associated with social capital (p<0.001) as well as condom self-efficacy (p<0.001); and (3) there were significantly positive associations between social capital and condom self-efficacy (p<0.001), and between condom self-efficacy and condom use (p<0.001). Moreover, social capital and condom self-efficacy fully mediated and buffered the negative effects between environmental and structural barriers and condom use.

Conclusion This is the first known study pointing to multiple relationships and pathways across multiple socioecological levels that can potentially be leveraged for future interventions aimed at improving condom use among Filipinx trans-WSM and cis-MSM. Such interventions should be multicomponent and build and/or strengthen social capital and condom self-efficacy, as well as intentionally target prominent structural and environmental barriers to condom use.

• HIV
• cross-sectional survey
• epidemiology
• prevention strategies
• public health

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### Key questions

• The Philippines is currently experiencing a national public health crisis that is concentrated among communities of transgender women and cisgender men who have sex with men (trans-WSM and cis-MSM, respectively), primarily due to condomless sex.

#### What are the new findings?

• The findings of this study modelled, for the first time, the various multilevel relationships and pathways across the socioecological model that can potentially be leveraged and addressed for future HIV prevention interventions that aim to improve condom use among these populations.

• Specifically, it highlighted the role of social capital and condom self-efficacy as key to increasing condom use while also acting as a buffer against the negative effects of structural and environmental barriers on condom use.

#### What do the new findings imply?

• The new findings provide support for widespread multicomponent condom interventions among trans-WSM and cis-MSM populations in the Philippines and in other settings alike, including promotion of social capital and condom self-efficacy.

## Background

Globally, communities of transgender women and cisgender men who have sex with men (trans-WSM and cis-MSM, respectively) are disproportionately impacted by the HIV epidemic.1–3 In the Philippines, where HIV is a national crisis, Filipinx (ie, gender and racially neutral term to describe citizens of the Philippines) trans-WSM and cis-MSM account for about four in five new HIV diagnoses annually since 2016.4 Moreover, the HIV prevalence is higher for trans-WSM and cis-MSM (1.7% and 4.9%, respectively), compared with the general population’s HIV prevalence of 0.1%.5 In the last decade, the country’s HIV epidemic has rapidly increased by more than fivefold, from 15 000 diagnosed cases in 2010 to 77 000 in 2018.5 Country surveillance reports have attributed trans-WSM and cis-MSM’s elevated risk for HIV infection primarily to condomless sex.5–8 According to UNAIDS, about 1 in 3 trans-WSM (out of the estimated population size of 122 800 trans-WSM) and about 1 in 2 cis-MSM (out of the estimated population size of 531 500 cis-MSM) have ever used condoms in the Philippines.5 Given the low uptake of condoms, it is important for the country’s public health efforts to understand factors that impact condom use among these two important communities.

Although condom use is often considered an individual-level behaviour, studies have shown that risks for condomless sex are shaped and exacerbated by social, environmental and structural factors and conditions.9–11 The socioecological model is a conceptual model developed to understand and organise multilevel predictors of a behavioural health outcome across individual, social, environmental and structural levels.9 In the literature of gender and sexual health, it has been hypothesised that trans-WSM and cis-MSM’s health inequities and behaviours arise from multiple, intersecting personal, social and structural stressors due their marginalised gender and sexual identities.10 In the context of the Philippines, the HIV literature among trans-WSM and cis-MSM communities remains scant,12 and no studies to date have applied the socioecological model to understand condom use behaviour in these two Filipinx communities.

Socioecological factors that contribute to condomless sex among trans-WSM and cis-MSM communities in other settings have been previously described.11 Some individual-level factors include having low self-efficacy in using condoms with casual and primary partners, and low condom knowledge.13 14 Social-level indicators include not having social capital to access and use condoms and other HIV prevention services.13–15 Environmental-level factors include inaccessibility and unavailability of condoms, and avoiding health services due to issues such as cost, distance and lack of competent providers.16–18 Structural-level factors include widespread violence (eg, transphobia, homophobia) due to identifying as part of marginalised gender and sexual communities (eg, lesbian, gay, bisexual, transgender (LGBT) community) and HIV communities.17 19–21 Moreover, structural factors such as lack of protective antidiscrimination policies have also been linked to lower condom use.22 23 The lack of protective structural factors such as antidiscrimination policies may drive trans-WSM and cis-MSM members away from attaining HIV prevention services like condoms. Taken together, these findings underscore the need for multilevel, high-impact condom intervention tailored to trans-WSM and cis-MSM populations.24–28

However, the studies conducted to date have generally focused on predictors of condom use at a single level of analysis, often situated at the individual level such as understanding how to increase knowledge, skills and attitudes towards improving use of condom,29–31 rather than examining condom use predictors at multiple levels simultaneously. To our knowledge, there are no studies that have assessed these multilevel factors to predict condom use in a unified conceptual framework using structural equational modelling (SEM) approach to demonstrate associations within and across levels simultaneously.10 12 As noted, social capital and self-efficacy are key variables within the socioecological model due to their relevance for public health interventions. Both variables theoretically operate as mechanisms linking upstream variables (structural and environmental factors) with condom use. Investigation of these theorised relationships can provide empirical support for the design of interventions aiming to strengthen social capital and self-efficacy as pathways to increase condom use and reduce HIV transmission among trans-WSM and cis-MSM. However, if there are direct associations between upstream variables and condom use that are not explained by social capital and self-efficacy (ie, as mediating variables), then it is unlikely that interventions addressing these specific mid-level variables can influence condom use. In this case, interventions must more directly target structural and environmental factors or identify alternative mid-level variables that account for the influence of upstream variables on condom use.

There is a clear need to improve condom utilisation among Filipinx trans-WSM and cis-MSM communities to reduce the spread of HIV in the Philippines.12 17 Currently, condom distribution programmes in the country face barriers to implementation. For example, the country’s Department of Health strategy for public condom distribution and educational programmes are currently facing strong oppositions from the Catholic Church.32 The Philippines’ population is 93% Catholic,33 and religious institutions are concerned that distributing condoms may encourage promiscuity and are, therefore, restricting availability of condoms only to health clinics and convenience stores.32 However, our formative qualitative study on barriers to condom use among Filipinx trans-WSM and cis-MSM found that despite condom availability in these venues, issues such as cost, distance to and from healthcare clinics and convenience stores, lack of privacy and feeling stigmatised when purchasing condoms continue to be salient barriers to condom use, leading many to avoid these venues.17

To understand how these multilevel factors of condom use are linked among Filipinx trans-WSM and cis-MSM, it is essential to examine pathways that explore how these factors interplay across the multiple socioecological levels. Using SEM, the purpose of this analysis is to: (1) to test our hypothesised model, displayed in figure 1, that condom use behaviour among these two communities are reinforced and/or enabled by personal, social, environmental and structural factors; and (2) to assess the direct, indirect (ie, mediating) and overall effects of associations between structural-level and environmental-level barriers to condom use, social-level social capital, and personal-level factor condom self-efficacy, and the outcome, condom use. Specifically, we hypothesised that:

Hypothesis 1: Social capital mediates the relationship between condom use and structural-level and environmental-level barriers to condom use.

Hypothesis 2: Condom self-efficacy mediates the relationship between condom use and structural-level and environmental-level barriers to condom use.

Hypothesis 3: Condom self-efficacy mediates the relationship between social capital and condom use.

Figure 1

Hypothesised model. Notes: error variance terms for measured variables are shown as ε. Model is adjusted for gender, age, location and income. LGBT, lesbian, gay, bisexual, transgender.

## Methods

### Setting

Data for this study were collected through a web survey of trans-WSM and cis-MSM in Manila and Cebu cities, Philippines. Manila and Cebu are the top two metropolitan Philippine cities where HIV prevalence are observed to be highest,8 and where TW and cis-MSM are likely to congregate. The study was conducted between June 2018 and August 2019.

### Sample

Participants were recruited via purposive sampling by posting the survey link at online venues where trans-WSM and cis-MSM are known to commune including: (1) private Facebook pages of local non-profit LGBT community-based organisations (CBOs); and (2) private member-only email listserv created by local CBOs.

To be eligible for this study, participants had to: (1) be at least 18 years old; (2) identify as either trans-WSM or cis-MSM; (3) self-report condomless anal sex in the past 12 months; (4) live in Manila or Cebu; (5) provide online written consent and (6) demonstrate English comprehension via a brief cognitive screening form. A brief cognitive screening form tested participants’ English comprehension via a series of true–false questions based on the consent form. Example questions include: ‘There is no cost for you to participate in this study’ (true/false), and ‘This study is voluntary’ (true/false). Moreover, we used the Flesch-Kincaid Reading Level Test to help ensure survey language was maintained a sixth grade level readability.34 In our formative qualitative work, conducting the study in English was not an impediment to recruiting, creating rapport and interviewing participants.

### Procedures

Participants interested in the study were screened for eligibility. Following electronic informed consent, participants answered the survey using their own device (eg, laptop, smartphones or tablet computers). The range of time for participants to complete the survey was between 20 min to 25 min.

We implemented a series of best practices for conducting online surveys.35 First, to confirm that actual human participants were taking the survey, a ‘captcha box’ was programmed into the survey to rule out robots.36 Second, to ensure that each survey was unique and that there were no duplicates, we systematically implemented a cross-validation programme that flagged duplicated (Internet Protocol) IP addresses.37 38 Any IP address that were not unique were blocked from taking the survey.

### Limitations

There are some limitations to this study that are worth noting. First, the cross-sectional data do not allow inferences about causation between exposure and outcome variables.79 Future research exploring this phenomena should use data from longitudinal study design, which can provide temporality and can strengthen findings of the mediation analysis. Second, because the levels of socioecological model are defined in various ways in the literature,21 80 81 it is possible that some of the variables that are hypothesised in this study may reside in a different level according to different interpretations of the socioecological model. Third, the variables assessed in this study are based on perceived individual-level experiences across the social, environmental and structural levels. As such, this analysis could be strengthened by having multiple sources of data that do not rely on self-reported measures (eg, administrative data, biomarkers, surveillance, assessment of existing antidiscrimination policies, etc). Fourth, this study used a convenience sampling approach through purposively targeting social media and email platforms and implemented English comprehension language screening. As such, the study findings are not representative of and cannot be generalised to all Filipinx trans-WSM and cis-MSM, particularly those who may not have access to these platforms and/or may lack English language comprehension. Lastly, the data were collected in a self-reported manner. While self-reports are conventional methods in behavioural research, self-reports are often prone to under-reporting particularly when questions probe participants’ personal behaviours and experiences that may be stigmatising.

## Conclusion

This study examined and linked together various multilevel predictors and mediators of condom use in Filipinx trans-WSM and cis-MSM communities. Taken together, the findings of this study call for multilevel interventions to improve condom use behaviours among Filpinx trans-WSM and cis-MSM. In particular, findings reveal that social capital and condom self-efficacy are important mediators to be considered for future interventions aiming to increase condom use and other HIV services among these communities. Such multicomponent interventions should involve building and/or strengthening community cohesiveness and participation and should carefully examine and intentionally target prominent barriers to social capital, condom self-efficacy and condom use.

## Acknowledgments

The authors's foremost appreciation goes out to the participants of this study. They thank their research assistants who made this study possible: Patricia Rodarte, Savannah Gomes, Bianca Obiakor, Emily Yoshioka and Valerie Santos.

## Footnotes

• Handling editor Seye Abimbola

• Contributors All authors were involved in the conceptualisation of this paper. AR, TS, ML, SC-U and DO designed the analysis for this paper and analysed the data. AR conducted the data analysis and wrote the paper. All authors reviewed the paper.

• Funding This work was supported by the National Institute of Health-Fogarty International Centre under Grant D43TW010565; Providence/Boston Centre for AIDS Research under Grant P30AI042853; the National Institute on Drug Abuse under Grant R36DA048682. AR is a recipient of the Robert Wood Johnson Foundation Health Policy Research Scholars and a Public Policy Fellow at amFAR, the Foundation for AIDS Research. AO’s contribution is supported by the National Institute on Drug Abuse under Grant R36DA047216. TS’s contribution is supported by NIMH Centre under Grant P30MH43520.

• Competing interests None declared.

• Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

• Patient consent for publication Not required.

• Ethics approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Brown University Human Research Protection Programme Institutional Review Committee in Providence, Rhode Island) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

• Provenance and peer review Not commissioned; externally peer reviewed.

• Data availability statement No data are available. Data cannot be shared publicly per IRB agreement on data sharing and to minimise participant risk and maximise privacy and confidentiality as much as possible. Data are available from the Brown University Institutional Data Access/Ethics Committee (contact via irb@brown.edu) for researchers who meet the criteria for access to confidential data.

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